Physical Health Exam

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Physical Health
Participant ID		_______________________
Name of Assessor		__________________(free type)
Name of Data Clerk		__________________(free type)
Date of assessment		______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)
Head/Fontanelle	 Normal  Normal	 Abnormal (please specify): __________________(free type)  Abnormal (please specify): __________________(free type)
Ears
Structure
Appears to hear/responds to sound	 Yes	 No (please specify): __________________(free type)
Eyes
Structure	 Normal	 Abnormal (please specify): __________________(free type)
Appears to see/responds to visual stimuli	 Yes	 No (please specify): __________________(free type)
Skin
Nevi	 No	 Yes (please specify): __________________(free type)
Café au lait spots	 No	 Yes (please specify): __________________(free type)
Bruising	 No	 Yes (please specify): __________________(free type)
Nose	 Normal	 Abnormal (please specify): __________________(free type)
Mouth and Throat	 Normal	 Abnormal (please specify): __________________(free type)
Teeth
Caries	 No	 Yes (please specify): __________________(free type)
Eruption	 Normal	 Abnormal (please specify): __________________(free type)
Appearance	 Normal	 Abnormal (please specify): __________________(free type)
Lungs	 Normal	 Abnormal (please specify): __________________(free type)
Heart	 Normal	 Abnormal (please specify): __________________(free type)
Femoral pulses	 Normal	 Abnormal (please specify): __________________(free type)
Abdomen	 Normal	 Abnormal (please specify): __________________(free type)
Genitalia	 Normal	 Abnormal (please specify): __________________(free type)
Structure	 Normal	 Abnormal (please specify): __________________(free type)
Male testes descended (if applicable)	 Yes	 No (please specify): __________________(free type)
Extremities and Hips	 Normal	 Abnormal (please specify): __________________(free type)
Arthrogryposis	 No	 Yes (please specify): __________________(free type)
Back	 Normal	 Abnormal (please specify): __________________(free type)